Autism hand book

A University Center for Excellence in
Developmental Disabilities Education, Research and Service
AUTISM AND
RELATED DISORDERS
HANDBOOK

Compiled by Julie Christian and Autism Program Staff
Autism and Related Disorders Program
Center for Disabilities
Department of Pediatrics
The University of South Dakota School of Medicine
1400 West 22nd Street
Sioux Falls, South Dakota 57105
1-800-658-3080 (Voice/TTY)
www.usd.edu/cd
The Autism and Related Disorders Handbook is available in alternate format upon request.
The Autism and Related Disorders Handbook was developed using federal funds as part of a grant
from the South Dakota Council on Developmental Disabilities.
Spring 2002

Table of Contents
Foreword............................................................................................................................... 1
Center for Disabilities Autism and Related Disorders Program............................................................ 2
Introduction to Autism Spectrum Disorder..................................................................................... 3
Pervasive Developmental Disorder Overview............................................................................. 4
Pervasive Developmental Disorder Chart.................................................................................. 6
Diagnostic Criteria .............................................................................................................. 7
Asperger’s Disorder............................................................................................................10
Legal Definition of Autism in South Dakota ..............................................................................12
Characteristics and Early Indicators of Autism ..........................................................................13
CHAT (Checklist for Autism in Toddlers)..................................................................................14
Intervention..........................................................................................................................16
Characteristics of and Support Strategies for Individuals with Autism.............................................17
Understanding and Supporting Individuals with Autism: What You Can Do......................................22
Discrete Trial Training.........................................................................................................23
Structured Teaching...........................................................................................................24
Visual Schedules................................................................................................................25
Enhancing Language and Communication in Children with Autism.................................................27
Strategies to Address Echolalia: Modeling Functional Communication.............................................28
Communication Temptations ................................................................................................30
Picture Exchange Communication System................................................................................31
A.P.P.R.E.C.I.A.T.E. the Child with Autism ...............................................................................32
Functional Assessment of Challenging Behaviors.......................................................................34
Positive Behavioral Supports ................................................................................................35
General Recommendations for Promoting and Enhancing Socialization ...........................................36
Social Stories....................................................................................................................37
Comic Strip Conversations ...................................................................................................38
Sensory Integration ...........................................................................................................39
Recommendations for Supporting Indiv iduals with High Functioning Autism....................................40
Pharmacological Interventions ..............................................................................................41
Evaluating Treatment Approaches and Nontraditional Therapies...................................................43
General Programming Ideas......................................................................................................45
Early Intervention in Autism.................................................................................................46
Educational Issues.............................................................................................................47
Person-Centered Planning and Transition to Adulthood...............................................................48
Bibliography ..........................................................................................................................49
Appendix A – Glossary of Terms ................................................................................................52
Appendix B – Glossary of Acronyms............................................................................................57
Appendix C – Organizations ......................................................................................................59
Appendix D – Journals and Newsletters .......................................................................................61
Appendix E – Publishers/Resource Providers .................................................................................62
Appendix F – Websites ............................................................................................................63

Center for Disabilities Autism and Related Disorders Program Autism and Related Disorders Handbook 1
Foreword
The Autism Handbook has been compiled and toiled over for several years. Its preliminary format was re-
searched and painstakingly developed through the efforts of Julie Christian, a former Center for Disabilities
Autism Specialist. Thank you, Julie, for all the time and energy you devoted to this!
Since Julie’s initial efforts, several other people have assisted in the development of the handbook. Thanks
go first to the families for providing the photographs and quotes that are found in the right margins of
some of the pages. The afternoon we spent together gathering and sharing will stay with us forever.
Thank you!
Next, editing credit goes to Pam Anderson, Kathy Miller and Heather Stettnichs. Thanks for minding the
grammar! Credit for the layout and design go to Liz Fox who has seen it through numerous changes.
Thank you, Liz, for your creativity and patience!
Lastly, thanks to Merrie Hammer for her artistic renderings of her son—past, present and future—to grace
our sections pages. What a joy he is.
Please know that this is meant as a resource guide and a starting point to answer questions about Autism
Spectrum Disorders. We hope you find it helpful.
Brittany Schmidt, M.A., CCC/SLP Tracy Stephens, Ph.D. Heather E. Hanzlick, M.S.
Director Autism Psychologist Asperger Specialist
Department of Pediatrics
The University of South Dakota
School of Medicine

The Center for Disabilities Autism and Related Disorders Program was established through the efforts of
parents of individuals with Autism Spectrum Disorders throughout South Dakota. These parents convinced
state legislators of their need for independent interdisciplinary assessments and individualized educational and
behavioral training for professionals. The Center for Disabilities Autism and Related Disorders Program is
funded by a grant from the South Dakota Division of Developmental Disabilities and administered through the
Center for Disabilities, Department of Pediatrics, the University of South Dakota School of Medicine.
A variety of assessment, consultative and training services are provided to families, schools, and adult service
agencies in South Dakota. The services provided by the Center for Disabilities Autism and Related Disorders
Program include:
• Observation and informal assessment of learning, communication, social skills, and daily living skills.
• Functional assessment of challenging behavior and assistance with the development of an appropriate
behavior support plan.
• Hands-on training, in-services and workshops for parents and professionals regarding specific
techniques and strategies.
• Consultation for the development of individualized programs, inclusion, and disability awareness
training.
• Clinic evaluations for diagnosis and assessment conducted by an interdisciplinary team of professionals
with experience and expertise in the area of autism.
• Family support groups.
• Autism Advisory Committee.
• Dissemination of information.
The Center for Disabilities Autism and Related Disorders program provides resources, including books, videos,
audiotapes, and journals on autism and other disability issues, through the Wegner Health Science Information
Center [800-658-3080 (Voice/TTY)].
Parents or service providers may call 800-658-3080 to request consultative, training or evaluation services or
send in a request for referral paperwork from our website, www.usd.edu/cd/autism. Clinic evaluations are
held in Sioux Falls.

Introduction to Autism Spectrum Disorders

Pervasive Developmental Disorders
Overview
According to the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV), Pervasive Developmental Disorder (PDD) is not a specific diagnosis, but an umbrella
term under which specific diagnoses are defined: Autistic Disorder, Asperger’s Disorder, Rett’s Disorder,
Childhood Disintegrative Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS).
These disorders are grouped together because they share common qualitative impairments in the areas of
social interaction, communication, and range of activities and interests. Currently, no medical tests can be
done to indicate the presence of these disorders. When an individual is suspected of having a Pervasive
Developmental Disorder, a review of the person’s developmental history in areas such as speech,
communication, social and play skills is critical as part of an evaluation. Ideally, an interdisciplinary team of
professionals including, but not limited to, a psychologist, an educator, a speech language pathologist, an
audiologist, and in some cases a physician, should evaluate the person and work together to determine an
appropriate diagnosis.
Autistic Disorder
Autism is a lifelong developmental disorder that affects an individual’s abilities in the areas of communication
and social interaction. Leo Kanner first described it in 1943. In his study of eleven boys, he distinguished it
from childhood schizophrenia. Criteria for diagnosis are arranged under three categories: social interaction;
communication; and restricted, repetitive and stereotyped behaviors and interests. An additional criterion
specifies the onset to have occurred before the age of three years. Autism occurs in 2-5 per 10,000 live
births, and 3-4 times more often in boys than girls. It is the third most common developmental disability.
Cognitive impairment often co-occurs with autism; 70-75% of people with autism also have mental retardation
(IQ below 70). Fifty percent of individuals with autism develop functional communicative language. Autism is
a spectrum disorder with symptoms ranging from mild to severe. The term high functioning autism is not a
diagnostic term, but is used to refer to individuals who have autism and normal to above normal intelligence.
The exact cause of autism is unknown; however, research has determined that it has a biological cause and it
is not psychological. While there are many strategies that assist an individual to learn important functional
skills, there is no treatment or intervention strategy that cures autism.
For more information: Autism Society of America
7910 Woodmont Avenue, Suite 300
Bethesda, MD 20814
(800) 3-AUTISM www.autism-society.org
Asperger’s Disorder
Asperger’s Disorder is a developmental disorder that is characterized by a severe impairment in the areas of
social interaction and restricted and unusual patterns of interest and behavior. Dr. Hans Asperger, a
pediatrician from Vienna, Austria, first described this disorder in 1944, one year after Leo Kanner first wrote
about autism. At the time they were unaware of each other’s work, but their patients shared many
commonalities. However, the children that Asperger observed were not as delayed in speech, and the onset
seemed to be later than the children studied by Kanner. Asperger’s Disorder was not officially recognized as a
diagnosis until 1994 when it was included in the DSM-IV.
For more information: Asperger Syndrome Coalition of United States
P.O. Box 351268
Jacksonville, FL 32235
866-4-ASPRGR (866-427-7747) www.asperger.org

Rett’s Disorder (Rett Syndrome)
Rett’s Disorder is a developmental disorder that occurs almost exclusively in females in 1 per 22,800 live
female births. Severe impairment of receptive and expressive communication and apraxia (dyspraxia) are
characteristic of Rett’s Disorder. The child has a period of normal development until age 5 months. Within 6-
30 months the child’s development stops or regresses. The child loses communication skills, which may be
mistaken for hearing loss, and purposeful use of the hands. Stereotyped hand movements (hand wringing or
hand washing), poor coordination of gait, and a slowing of the rate of head growth appear following the
regression. Seizures and disorganized breathing patterns may also occur. Rett’s Disorder is most often
misdiagnosed as autism, cerebral palsy, or non-specific developmental delay. It was first described by Dr.
Andreas Rett from Vienna, Austria and was recognized throughout the world in 1983. The October 1999 issue
of Nature Genetics (Vol. 23) reports that the protein MeCP2 is responsible for Rett’s Disorder. This establishes
Rett’s Disorder as the first human disease caused by defects in a protein involved in DNA methylation. The
research also supports Rett’s Disorder being added to a small but growing number of human genetic disorders
that involve abnormal chromatin packaging and gene expression.
For more information:
International Rett Syndrome Association
9121 Piscataway Road
Clinton, MD 20735
(800) 818-RETT
www.rettsyndrome.org
Childhood Disintegrative Disorder
Dr. Theodore Heller first identified Childhood Disintegrative Disorder (CDD),
also known as Heller’s Syndrome, in 1908 in Vienna, Austria. CDD is
characterized by regression in development after at least two years of normal
development. Prior to the regression, the child exhibits age-appropriate play
and communication skills. The loss of skills usually develops gradually before
the age of 10 years in at least two of the following areas: expressive or
receptive language, social skills, bowel or bladder control, play skills, or motor
skills. A period of unspecified anxiety or agitation may occur prior to the
regression. Generally, the regression occurs between the ages of three and
five years. Following the loss of skills, CDD is difficult to distinguish from
autism. Therefore, the history of the child’s development is critical to an
accurate diagnosis. Childhood Disintegrative Disorder has a prevalence rate of
1 per 100,000 births, affecting more males than females.
Pervasive Developmental Disorder-Not Otherwise Specified
(PDD-NOS)
Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) is
diagnosed when an individual has a severe and pervasive impairment in the
development of reciprocal social interaction or verbal and nonverbal
communication skills, or when behavior, interests, and activities are present,
but the criteria are not met for a specific Pervasive Developmental Disorder.
This category also includes “atypical autism,” for example, presentations that
do not meet the criteria for Autistic Disorder because of late age of onset,
atypical symptomatology, or subthreshold symptomatology. A common
misunderstanding about PDD-NOS is that it is “mild autism.” This is not
accurate. Although PDD-NOS is a separate diagnosis from autism, the same
interventions may be effective for both diagnoses.
“When our son was small
he was stung by a bee.
He didn’t cry, he didn’t
even seem to notice. But
he would cry as if he
were in intense pain if he
didn’t get exactly ten
pushes on the swing. We
think it really did hurt
him.”
“When our son was 2½
to 3 years old he made a
complex electrical circuit.
He could problem solve
the steps necessary to
make it work but he
could not ask us for a
glass of milk.”

Autism Spectrum Disorders =
Pervasive Developmental Disorders (PDD)
Pervasive
Developmental
Disorders
Autism PDD-NOSChildhood
Disintegrative
Asperger’s
Disorder
Rett’s
Pattern of deficits:
social, communication, behavior/interests,
onset prior to 3 years of age
Pervasive Developmental Disorders Chart

Diagnostic Criteria
The following is taken from the DSM-IV published in 1994 by the American Psychiatric Association.
299.00 Autistic Disorder
(A) A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2)
and (3):
(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze,
facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other
people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an
attempt to compensate through alternative modes of communication such as gestures or
mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain
a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to
developmental level
(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested
by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest
that is abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or
complex whole-body movements)
(d) persistent preoccupation with parts of objects
(B) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
(1) social interaction,
(2) language as used in social communication, or
(3) symbolic or imaginative play.
(C) The disturbance is not better accounted for by Rett’s Disorder of Childhood Disintegrative Disorder.

299.80 Rett’s Disorder
(A) All of the following:
(1) apparently normal prenatal and perinatal development
(2) apparently normal psychomotor development through the first five months after birth
(3) normal head circumference at birth
(B) Onset of all of the following after the period of normal development:
(1) deceleration of head growth between ages 5 and 48 months
(2) loss of previously acquired purposeful hand skills between ages 5 and 30 months with the
subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)
(3) loss of social engagement early in the course (although often social interaction develops later on)
(4) appearance of poorly coordinated gait or trunk movements
(5) severely impaired expressive and receptive language development with severe psychomotor
retardation
299.10 Childhood Disintegrative Disorder
(A) Apparently normal development for at least the first 2 years after birth as manifested by the presence of
age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.
(B) Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following
areas:
(1) expressive or receptive language
(2) social skills or adaptive behavior
(3) bowel or bladder control
(4) play
(5) motor skills
(C) Abnormalities of functioning in at least two of the following areas:
(1) qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to
develop peer relationships, lack of social or emotional reciprocity)
(2) qualitative impairments in communication (e.g., delay or lack of spoken language, inability to
initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-
believe play)
(3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including
motor stereotypies and mannerisms
(D) The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by
Schizophrenia.
299.80 Asperger’s Disorder
(A) Qualitative impairment in social interaction, as manifested by at least two of the following:
(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial
expression, body postures, and gestures to regulate social interaction
(2) failure to develop peer relationships appropriate to developmental level

(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
(e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
(4) lack of social or emotional reciprocity
(B) Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at
least one of the following:
(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that
is abnormal either in intensity or focus
(2) apparently inflexible adherence to specific, nonfunctional routines or rituals
(3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or
complex whole-body movements)
(4) persistent preoccupation with parts of objects
(C) The disturbance causes clinically significant impairment in social, occupational, or other important areas
of functioning.
(D) There is no clinically significant general delay in language (e.g., single words used by age 2 years,
communicative phrases used by age 3 years).
(E) There is no clinically significant delay in cognitive development or in the development of age-appropriate
self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in
childhood.
(F) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
299.80 Pervasive Developmental Disorder Not Otherwise Specified (Including Atypical
Autism)
This category should be used when there is a severe and pervasive impairment in the development of
reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior,
interests, and activities are present, but the criteria are not met for a specific Pervasive Developmental
Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. For example, this
category includes “atypical autism” — presentations that do not meet the criteria for Autistic Disorder because
of the late age of onset, atypical symptomatology, or subthreshold symptomatology, or all of these.

Asperger’s Disorder
• socially awkward
• naïve and gullible (easy target for bullies)
• often unaware of others’ feelings
• less developed conversational skills and difficulties with
the give and take in conversations
• inappropriate body language or facial expressions
• difficulty managing stress; emotionally vulnerable
• unusually loud, high or monotonous voice or stilted
manner of speaking
Asperger’s Disorder (also known as Asperger Syndrome) is a newly recognized neuro-biological disorder that
is a part of the Autism Spectrum (Pervasive Developmental Disorders). The disorder is named for the
Viennese physician, Hans Asperger. In a 1944 paper, he described a group of young boys who displayed
normal intelligence and language development, but who also demonstrated serious social, behavioral and
communication impairments. Han Asperger’s paper was not translated until the 1980’s. Hence, Asperger
Syndrome was not added to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-
IV) until 1994.
Due to the relatively recent identification of the disability, some professionals, parents, and individuals
dealing with the disability and the general public have really only begun to become aware of the needs and
concerns associated with the disorder. However, Asperger awareness is increasing. The number of
individuals affected is approximately within the range of 1 in 200 or 250 individuals (Kadesjo, Gillberg, and
Hagberg, 1999).
Because research at this point indicates that the disability affects so many people, researchers and
practitioners have gone to great lengths to identify and develop strategies that can facilitate school and
home success.
Overview of the DSM-IV Diagnostic Criteria
• Impairment in social interaction
• Restricted, repetitive and stereotyped patterns of behavior, interests and activities
• Clinically significant impairment in social, occupational or other areas of functioning
• No clinically significant general delay in language (single words by two and phrases by three)
• No clinically significant delay in cognitive development or adaptive skills (outside social challenges)
Real World Examples
Children, young people and adults with Asperger’s Disorder may display some and/or all of the following
characteristics:
• socially awkward
• naïve and gullible (easy target for bullies)
• often unaware of others’ feelings
• less developed conversational skills and difficulties with the give and take in conversations
• inappropriate body language or facial expressions
• difficulty managing stress; emotionally vulnerable
• unusually loud, high or monotonous voice or stilted manner of speaking
• limited play and leisure skills
• unusually accurate memory for details
• difficulty with sleeping or eating
• trouble with organizational skills
• difficulty taking the perspective of others
• easily upset by changes in routine
• literal in speech and understanding
• intense areas of interest
• unusual speech patterns (repetitive or irrelevant remarks)
• lacking peer and friendship establishment
• lacking an understanding of human relationships

With the push toward more appropriate program development, a whole host of new resources relating to
Asperger’s Disorder has emerged. This is very exciting, but can be precarious for individuals looking for
good places to begin. The following resources are extremely helpful in terms of describing the disability,
providing background information and outlining helpful supports and strategies for home and classroom
implementation.
In addition, if anyone has concerns whether or not an individual has Asperger’s Disorder, the Australian
Scale for Asperger Syndrome (ASAS) is available on the internet (see Tony Attwood’s web site listed below)
or in Tony Attwood’s text, Asperger Syndrome. The ASAS is a questionnaire designed to help identify
individuals who have concerns and may need further assessment. This assessment tool can help families
and professionals make decisions regarding the need for referral for further assessment related to
Asperger’s Disorder and can help with initial identification of areas of concern that need to be addressed.
For more information, contact the Center for Disabilities Autism and Related Disorders program.
Asperger’s Disorder Resources
Asperger’s Syndrome: A Guide for Parents and Professionals by Tony Attwood (also on video)
What Does It Mean to Me? A Workbook Explaining Self Awareness and Life Lessons to the Child or Youth
with High Functioning Autism or Asperger by Catherine Faherty
Do-Watch-Listen-Say: Social and Communication Intervention for Children with Autism by Kathleen Quill
Asperger Syndrome: A Guide for Educators and Parents by Brenda Smith Myles and Richard L. Simpson
Asperger Syndrome and Difficult Moments by Brenda Smith Myles
Asperger Syndrome and Adolescence: Practical Solutions for School Success by Brenda Smith Myles and
Diane Adreon
The resources cited above can be obtained through the Wegner Health Science Information Center at
1-800-521-2987.
Websites
www.udel.edu/bkirby/Asperger
www.aspie.com
www.tonyattwood.com

Legal Definition of Autism in South Dakota
South Dakota Administrative rules pertaining to eligibility criteria for autism:
24:05:24.01:02. Screening procedures for autism
If a student is suspected of having autism, screening procedures for autism shall include a review of
any medical, hearing, and vision data on the student; the history of the student’s behavior;
and the student’s current patterns of behavior related to autism.
24:05:24.01:03. Autism defined
Autism is a developmental disability that significantly affects verbal and nonverbal communication and
social interaction and results in adverse effects on the student’s educational performance.
Other characteristics often associated with autism are engagement in repetitive activities and
stereotyped movements, resistance to environmental change or change in daily routines, and unusual
responses to sensory experiences.
The term does not apply if the student’s educational performance is adversely affected primarily
because the student has a serious emotional disturbance as defined under Part B of the Individuals
with Disabilities Education Act as in effect on November 13, 1992.
24:05:24.01:05. Diagnostic procedures for autism
School districts shall refer students suspected as having autism for a diagnostic evaluation to an
agency specializing in the diagnostic and educational evaluation of autism or to another
multidisciplinary team or group of persons who are trained and experienced in the diagnosis and
educational evaluation of persons with autism.
A student suspected of autism must be evaluated in all areas related to the suspected disability,
including, where appropriate, health, vision, hearing, social and emotional status, general intelligence,
academic performance, communicative status, and motor abilities.
The evaluation shall utilize multiple sources of data, including information from parents and other
caretakers, direct observation, performance on standardized tests of language/communication and
cognitive functioning and other tests of skills and performance, including specialized instruments
specifically developed for the evaluation of students with autism.
24:05:24.01:06. Instruments used in diagnosis of autism
Instruments used in the diagnosis of students suspected of having autism include those which are
based on structured interviews with parents and other caregivers, behavior rating scales, and other
objective behavior assessment systems.
Instruments used in the diagnosis of students with autism must be administered by trained personnel
in conformance with the instructions provided by their producer.
No single instrument or test may be used in determining diagnosis or educational need. Specific
consideration must be given to the following issues in choosing instruments or methods to use in
evaluating students who are suspected of having autism:
(1) The student’s developmental level and possible deviations from normal development
across developmental domains;
(2) The student’s primary mode of communication;
(3) The extent to which instruments and methods identify strengths as well as deficits; and
(4) The extent that instruments and methods are tailored to assess skills in relationship to
everyday activities and settings.

Characteristics and Early Indicators of Autism
Communication
• Uses behavior to express feelings
• Lack of development or delayed development of speech
• Echolalia (questions statements, sounds), delayed or immediate
• Perseverates on one topic
• Atypical tone or rhythm of speech
• Lack of or infrequent initiation
• Expresses emotions inappropriately
• Displays a narrow range of emotion, may have a flat affect
• Lack of conventional nonverbal gestures (i.e., pointing, head shake, nod)
• Doesn’t orientate to another person speaking
Social Interaction (relating to adults, interacting with peers, and imitating the actions of others)
• Lacks understanding of social cues
• Inability to engage in simple social games such as pat-a-cake or peek-a-boo
• Difficulty in forming interpersonal relationships
• Avoids or uses eye contact in odd ways
• “Looks through” people
• Prefers to be alone or plays parallel to other children
• Lack of pretend or symbolic play
• Deficit in the development of joint attention
• Inability to imitate (body movement, vocal, motor)
Behavior (play and use of objects, insistence on sameness and routines, stereotyped body
movements, unusual sensory interests)
• Uses toys in odd ways such as lining them up, spinning, etc.
• Engages in perseverative, unconstructive play
• Engages in repetitive body movements such as rocking, pacing, hand flapping, toe walking, spinning
• Develops attachments to inanimate objects
• Resists change in routine, people or environments (insists on sameness)
Other Characteristics and Early Indicators of Autism
• Over- and under-sensitivity to sound, smell, touch, visual stimulus and pain
• Physical overactivity or extreme passivity
• May appear to be deaf
• May not be cuddly or seek physical comfort from parents/caregiver
• Unusual display of emotion, for example, giggling or weeping for no apparent reason
• Uneven patterns of cognitive and motor development
• Problems sleeping
• Short attention span
• Impulsivity
• Lack of fear
• Abnormal eating habits
• Self-injurious behavior
• Aggressive behavior

CHAT (Checklist for Autism in Toddlers
To be used by physicians or health visitors during the 18-month developmental check-up.
Child’s Name_____________________________________________________________
Date of Birth_____________________ Age____________________
Child’s Address___________________________________________________________
Phone Number_____________________________Parents_________________________
Parent(s) Signature_________________________________________________________
Section A. Ask Parent:
Date completed:_______________ Circle Yes/No
1. Does your child enjoy being swung, bounced on your knee, etc.? yes no
2. Does your child take an interest in other children? yes no
3. Does your child like climbing on things, such as up stairs? yes no
4. Does your child enjoy playing peek-a-boo/hide-and-seek? yes no
5. Does your child ever pretend, for example to make a cup of tea,
by using a toy cup and a toy teapot, or pretend other things? yes no
6. Does your child ever use his/her index finger to point to ask for something? yes no
7. Does your child ever use his/her index finger to point, to indicate interest
in something? yes no
8. Can your child play properly with small toys (e.g., cars or blocks/bricks)
without mouthing, fiddling or dropping them? yes no
9. Does your child ever bring objects over to you (parent) to show
you something? yes no
Section B. Physician or health visitor’s observation:
1. During the appointment, has the child made eye contact with you? yes no
2. Get the child’s attention, then point across the room at an interesting
object and say: “Oh, look? There’s a (name a toy)!” Watch the child’s
face. Does the child look across to see what you are pointing at? yes no *
3. Get the child’s attention, then give the child a miniature toy cup and
teapot and say, “Can you make a cup of tea?” Does the child pretend to
pour out tea, drink it, etc.? yes no *

4. Say to the child, “Where’s the light?” or “Show me the light.” Does the
child point with his/her index finger to the light? yes no *
5. Can the child build a tower of blocks/bricks? (If so, how many?)
Number of blocks/bricks______. yes no
SCORING & INTERPRETING THE CHAT
SCORING:
Section B-----3 Key Items:
Question #2 (skill: protodeclaritive pointing): To record yes on this item, ensure that the child has not simply
looked at your hand, but has actually looked at the object you are pointing to.
Question #3 (skill: pretend play): If you can elicit an example of pretend play in some other game, score a
yes on this item.
Question #4 (skill: gaze monitoring): Repeat this item with “Where’s the teddy bear?” or some other
reachable object, if the child does not understand the word “light.” To record yes on this item, the child must
have looked up at your face around the time of pointing.
INTERPRETING:
If a child fails all 3 key items on 2 or more administrations of the CHAT (at age 18 months), that child has an
increased risk of being diagnosed with autism. The child should be referred for further evaluation by a multi-
disciplinary team trained in the assessment and diagnosis of Autism Spectrum Disorders.
If a child consistently fails question #2 and/or question #3, that child has an increased risk that he/she will
be diagnosed with a language delay. Appropriate assessment and referrals are recommended in this
situation as well.
To refer a child suspected of having characteristics associated with an Autism Spectrum
Disorder, please contact the Center for Disabilities, Autis m and Related Disorders Program at
(605) 357-1431 or 1-800-658-3080 (V/TTY). We can also be reached via e-mail at
bdschmid@usd.edu or at www.usd.edu/cd.
Scoring and interpretation guidelines adapted from the research articles:
“Psychological Markers in the Detection of Autism in Infancy in a Large Population,” British Journal of
Psychiatry, (1996), Vol. 168, pages 158-163. Authors: S. Baron-Cohen & Anthony Cox, et.al.
“A Screening Instrument for Autism at 18 Months of Age: A 6-year Follow-up Study,” Journal of American
Child and Adolescent Psychiatry, (2000), Vol. 39(6), pages 694-702. Authors: Gillian Baird, Tony Charman,
Simon Baron-Cohen, Anthony Cox, et.al.

Intervention

Characteristics of and Support Strategies
for Individuals with Autism
Cognitive/Learning Style
Characteristics Support Strategies
1. Developmental discontinuity
a. Strengths
1. Understanding visual information
2. Understanding spatial information
3. Understanding concrete rules and information
4. Motor memory
5. Good rote memory
1. Use gestures, demonstrate and provide physical
prompts, use visual clues.
2. Be organized, help learner organize.
3. Be direct, be clear, be consistent.
4. Keep motor patterns predictable.
5. Reinforce it.
b. Weaknesses
1. Understanding symbols
2. Understanding means-ends and cause-effect
3. Understanding time-based information
4. Understanding abstract concepts and abstract
information
5. Imitation
6. Ability to generalize
1. Teach symbols very systematically, pair symbols with
words.
2. Have very clear beginnings and ends to activities,
teach routines.
3. Use visual and auditory cues for time issues, picture
schedules, written schedules, have learner
involved in setting up and using schedule (have
some motor aspect involved).
4. Use concrete, visual cues to illustrate concepts, relate
concepts to personal experience.
5. Give time to respond, may need physical cue to
begin, imitate the learner (playfully).
6. Use consistent cues, prompts, and consequences;
teach in natural environments; teach
(systematically) across a variety of places,
people, and materials; with new skills, change
one dimension of task at a time.
2. Typically learns things as “wholes” Whole task presentation, global chaining, prompt
placement, discrete trial format for instruction.
3. Difficulty identifying relevant cues Highlight relevant cues.
4. Concern with maintaining sameness Respect it, help the learner feel safe, teach strategies to
manage change gradually.
5. For some, verbal IQ equals or exceeds performance
IQ
Find opportunity for learner to use and be valued for
those verbal skills.
6. May have talent in art, music or mathematics Capitalize on that talent. Use it as an entry into various
social groups.

Sensory Processing
1. Extremely passive or hyperactive Be a detective – observe what kinds of places, people,
activities, stimuli, seem to make the learner more or less
active and attentive.
2. May experience sensory input differently (either more
or less sensitive)
Be sensitive to the kind of sensory input the learner
seems to seek out and avoid. Provide opportunities for
learner to get the kind of stimulation she/he seeks
(sensory diet). Try to minimize contact with stimuli that
are aversive. Teach coping skills for when she/he, must
experience stimuli that are irritating or painful.
3. May have unusual sleep patterns Help families establish bedtime routines, possibly
including direct reinforcement for participating in
routine.
4. Frequently handles objects in unusual ways Provide objects that can be handled in learner’s
preferred manner or provide same/similar input/
feedback. Find activities that incorporate learner’s
movements. Teach functional use of objects.
5. May have some excessive self-stimulatory behaviors Use sensory diet. Try to find ways for the individual to
experience the stimulus (e.g., using a fan, a rocking
chair). Teach when and where the behavior is okay.
Reduce or increase other stimulation. Use prompts,
cues and behavioral intervention to reduce the
frequency of the behavior.
6. Changing levels of arousal Be aware of it – watch for signs of arousal. Assign
meaning to the behavior. Develop and teach use of
communication system. Use sensory diet.
Movement
1. Starting
Difficulties may be seen as: frustration, avoidance,
noncompliance, not understanding, cognitive
challenge, nonverbal, rituals
Physical prompts.
Prompt placement.
Visual cues and within-stimulus prompts.
Systematic instruction.
Reasonable accommodations.
Routines.
Clear (dramatic in some cases) beginning points.
2. Executing
Difficulties may be seen as noncompliance, echolalia,
rituals, rigidity
Physical prompts.
Prompt placement.
Routines.

Movement, continued
3. Continuing
Difficulties may be seen as prompt dependent,
noncompliance, short attention span, distractibility
Use of individualized schedules.
Frequent change of activities and/or materials.
Minimize transitions (time and movement).
Physical prompts.
Routines.
4. Stopping
Difficulties may be seen as: perseveration, rituals,
self-stimulatory, rigidity
Provide similar alternative activities and/or objects.
Clear (dramatic at times) end points
Teach coping strategies.
Physical prompts.
Routines.
5. Combining
Difficulties may be seen as: prompt dependent,
processing problem
Chaining.
Physical prompts.
Routines.
6. Switching
Difficulties with transitions
Teach coping skills when switches need to occur.
Provide sufficient time to make switches.
Physical prompts.
Routines.
7. Variable performance Recognize and accommodate for varied performance.
Communication Skills: Expressive
1. Nonverbal (approximately 50%) Develop and use augmentative communication systems.
Encourage learner to “show” you or “take” you.
2. If talking, may not readily use speech to
communicate
Acknowledge nonverbal attempts. Present
“communicative temptations.” Use natural/meaningful
contexts and materials. Assess communicative
functions.
3. Echolalic (repeats what has been said, immediately
or delayed)
Simple language, avoid excessive talking, assess
functions, segment utterances by using stress,
intonation, and pause, relate echolalia to aspects of the
environment, use and teach gestures.
4. Language use give the impression of being learned
by rote
Model and reinforce creative language, provide regular
and systematic access to competent peer models.
5. Pedantic (rhythmic and/or varied intonation; may
also include repetitive questions on topics)
Teach appropriate time and place. Don’t take it
personally.
6. Repetitive speech Redirect and refocus. Introduce and expand topic
repertoire.

Communication Skills: Expressive, continued
8. Abnormal voice modulation Model, dramatic model, direct instruction.
9. Pronoun reversal Teach use of names instead.
10. Hyperverbal Stimulus control (teach time and place), concrete visual
cues and feedback.
11. Poor nonverbal communication Respond to any attempts at communication, use and
teach gestures.
12. Difficulty expressing emotions conventionally Teach coping strategies. Assess meaning of behavior.
13. Limited two-way conversation: turn taking, topic
maintenance, lack of referents
Direct instruction. Take responsibility for repair
strategies. Communication dictionary. Train peers to
accommodate and make repair strategies.
Communication Skills: Receptive
1. Often appears selectively deaf Provide physical touch prior to or paired with verbal
input.
2. Requires additional time to understand or respond to
verbal input alone
Provide time (up to 30 seconds), pair verbal input with
visual cues and material.
3. Difficulty responding to and interpreting social
gestures/information
Exaggerate cues, draw attention to social information,
provide direct social skills instruction.
4. Literal Limit use of idioms, double-meanings, and
colloquialisms.
Social/Emotional
1. Often appears more interested in objects than people Be open to and share interest in objects. Show how
objects can be shared with or used cooperatively.
2. Imaginative play is limited, lacks creativity, flexibility,
and spontaneity
Choose simple schemes at first and encourage
participation. Teach schemes then gradually expand.
3. May demonstrate attachment in unique ways Recognize and respond to the way the learner
demonstrates attachment.
4. Apparent lack of shared reference Provide feedback when it does not occur. Model it,
emphasize establishing joint reference if necessary.
Provide visual cues (written or other). Instruct directly.
Have good models. PRACTICE!
5. Sometimes difficult to console Move gently, be sensitive, and do the best you can.
Some learners may need space, some touch, some
quiet, and some may need you to talk/sing.
6. Frequent repetitive, ritualistic play; limited range of
interests/activities
Choose simple schemes at first and encourage
participation. Teach schemes, then gradually expand.
7. Demonstrate lack of anticipatory response Establish routines and practice them. Role play may
help with some learners. Provide additional cues.
Foreshadow.
7. Literal Recognize and respond to way the learner
communicates.

Social/Emotional, continued
9. May demonstrate self-stimulatory or stereotypic
behaviors
Provide objects that can be handled in learner’s
preferred manner or provide same/similar input/
feedback. Find activities that incorporate learner’s
movements. Teach when and where the behavior is
okay. Reduce or increase other stimulation. Use
prompts, cues and behavioral intervention to reduce the
frequency of the behavior.
10. Experiences entire range of emotions Work at recognizing and interpreting how the learner
expresses various emotions.
11. One-sided social interaction Work on turn-taking, use of concrete visual cues,
dramatic modeling, coaching, provide regular
opportunities to be with socially competent peers.
12. Demonstrates difficulty learning and using the rules
of social interaction
Make rules as clear and concrete as possible. Provide
good models (younger, same-aged, and older). Provide
direct instruction in social skills. Use dramatic modeling.
Use coaching and foreshadowing. Have the student
practice (usually in natural settings). Teach peers about
differences. Use and teach peers to use reasonable
accommodations.
13. May demonstrate apparent lack of empathy Coach and teach expressions of empathy. Allow
sufficient time for expression.
14. Naïve, inappropriate, lack of intuition Be sensitive to the difficulty. Foreshadow about a
situation when possible. Allow sufficient time for person
to express intuit ion.
15. Perspective-taking Teach cues to which the learner should attend. Teach
responses to cues. Teach others to communicate their
feelings/needs immediately, directly and concretely.
16. May demonstrate high levels of anxious behaviors Systematically teach coping and relaxation strategies.
Make reasonable accommodations. Use systematic
desensitization.
17. Seen as eccentric in school Teach peers about differences. Encourage and model
acceptance and celebration of differences. Frame
eccentricities as talents when possible.
18. Awareness of being different from others,
usually around puberty, bringing on over-sensitivity
to criticism, anxiousness, and/or depression
Create supportive social network. Listen and be
supportive. May need counseling, help student contact
a therapist.
19. Expresses a desire to make social contact, but no,
few or unconventional attempts
Help learner establish a social network. Provide regular
and systematic opportunities for interaction with peers.
Directly and systematically teach social skills. Act as an
interpreter for the learner. Sensitize peers to learner’s
needs.
8. Difficulty with change and transitions Use visual schedules and other visual and motor
organizers. Use foreshadowing. Make beginnings and
endings of activities and transitions clear. Help the
learner organize for and during the transition.

Understanding and Supporting Individuals
with Autism: What You Can Do
• Use simple language (vocabulary and structure) that is familiar to the individual.
• Allow for processing time needed by the student (this can often be as much as 30 seconds!)
• Use and teach conventional gestures or other communication systems if necessary.
• Do not always require eye contact.
• Use concrete and visual cues whenever possible.
• Always ask, “What could she be saying with this behavior?”
• Be sure activities have clear beginnings and endings.
• Focus on naturally occurring cues to facilitate generalization.
• Identify activities that give the individual opportunities to use her/his
interests and highest level skills.
• Avoid “changing the rules” whenever possible.
• Make rules as clear, specific and concrete as possible.
• Establish predictable routines to assist in making daily activities predictable.
• Provide definite visual structure and a visual schedule throughout the
day and during each activity.
• Only use prompts that can be easily faded.
• Teach a task, activity, or skill as a whole and in the natural environment.
• To facilitate social play, identify simple, age appropriate activities that are of high interest to peers.
• Choose activities that require simple social interactions.
• Be creative.
• Be flexible.
• Maintain a sense of compassion and a sense of humor.
“We spent weeks
preparing our son for his
school pictures we
practiced, ‘Say cheese’
and then he would smile.
The photographer
insisted on saying, ‘Say
pizza.’ Our son had the
worst photograph ever.
We never did see it, he
wouldn’t bring it home.”

Discrete Trial Training
Discrete trial training is usually associated with the work of O. Ivar Lovaas, a professor of psychology at the
University of California, Los Angeles (UCLA), which he began in the 1960’s. It is based upon the principles of
Applied Behavior Analysis (ABA), which may also be referred to as behavior modification, behavior therapy, or
behavioral intervention. Discrete trial training consists of a series of distinct repeated lessons or trials taught
one-to-one. Each trial consists of an antecedent, a “directive” or request for the child to perform an action;
the behavior, a “response” from the child; and the consequence, a “reaction” from the therapist based upon
the response of the child. Positive reinforcers are selected by evaluating the child’s preferences. Many
children initially respond to tangible or concrete reinforcers such as food items. These concrete rewards are
faded as fast as possible and replaced with rewards such as praise, tickles, and hugs. The final part of a
discrete trial is a short pause between the consequence and the next instruction called the between-trials
interval.
Early intensive behavioral intervention such as the Lovaas program is usually implemented when the child is
young, before the age of six. Services are highly intensive, typically 30-40 hours per week, and conducted on
a one-to-one basis by a trained therapist in the family’s home. Another component of the program is parent
training. The child’s progress is closely monitored by the collection of data on the performance of each trial.
After a skill has been mastered, another skill is introduced, and the mastered skill is placed on a maintenance
schedule. A maintenance schedule allows for periodic checking so the child does not regress in mastered
skills. Advantages and disadvantages to this intensive approach have been the subject of debate in literature
and should be researched carefully before implementation.
Discrete trial training is a technique that can be an important element of a comprehensive educational
program for the child with an Autism Spectrum Disorder. In some cases, a much less intensive, informal
approach may be implemented by a knowledgeable professional to teach specific skills such as sitting and
attending.
Order and simplification are the first steps
toward the mastery of a subject
-- the actual enemy is the unknown.
—Thomas Mann—
German novelist and critic Thomas Mann explored the exceptional individual
and his relationship to the environment of family or the environment of the
world.

Structured Teaching
The ability to process visual information is generally an area of strength for individuals with autism spectrum
disorders. Therefore, seeing something increases their understanding. However, they typically have difficulty
scanning, selecting and making sense of the relevant and important details in the environment. In addition,
individuals with autism may also have difficulty organizing themselves and planning their movements.
Structured teaching is the strategy of organizing space to clarify where activities happen, where things are
located, and how to transition from one place to the next. This strategy is based on the TEACCH (Treatment
and Education of Autistic and Related Communication Handicapped Children) approach, developed in the early
1970’s by Eric Schoppler and Gary Mesibov at the University of North Carolina, Chapel Hill.
There are five basic steps for organizing space:
1. Assess to address unique sensory and spatial problems.
2. Identify the location of activities.
3. Organize and refine the structure of the space.
4. Locate and label materials and supplies.
5. Continue to evaluate and refine.
By structuring space for the individual with autism, relevant details are emphasized and organization is built
into the environment. The following are a few examples for providing structure:
• A carpet square for the child to sit on during circle time.
• Tape on the floor to indicate where the child should stand during the Christmas concert.
• Sticky-notes placed in each corner of a table or at the left top and the right bottom corner of a window
identifies starting and ending points for cleaning. The individual is taught to work from top to bottom
and left to right, removing the notes as each area is finished.
• A specifically designed work area with physical boundaries depending upon the individual's needs.
• Work systems that communicate to the individual what work, how much and when they are finished with
the task.
• Visual Schedules (see page 25).
Structured teaching enhances participation, independence and success for the individual with autism.

Visual Schedules
A visual schedule presents the abstract concept of time in a concrete form. The schedule communicates to
the person with an autistic spectrum disorder when events/activities will take place and what will come next in
a clear, stable, concrete and uncluttered manner. This strategy assists her in predicting and planning.
Successful implementation of a visual schedule will often decrease challenging behaviors due to the increase in
effective communication.
There are several steps to implementing an effective individual visual schedule. The first step is to assess the
individual’s level of understanding of different forms of visual communication. If, for example, the individual
understands some photos, but generally is at an object level, the schedule may consist of a combination of
objects and photos. As the individual demonstrates understanding of the objects, they may be paired with the
photo to teach the individual the meaning of the photo. The object may be faded or removed when the
individual is able to demonstrate understanding of the photo. Always pair the written word with photos and
picture symbols.
The hierarchy of visual communication (least abstract to most abstract):
1. Objects (whole object, miniature object, partial object)
2. Photos
3. Picture Symbols (line drawings such as Mayer-Johnson Picture Communication Symbols)
4. Written Words
Once the type of visual communication has been selected, the schedule can be constructed. Specific
information should first be considered such as how the schedule will be used. Where it will be managed?
Who will manage it? How will the individual transition between the schedule and the activities/places on the
schedule?
The schedule should be easy to create and use, accessible to the individual, durable, inexpensive, flexible,
visually clear (free of unnecessary details and decoration), and appropriate to the age and skill level of the
individual. Depending upon the skill level of the individual, the schedule may need to be presented in parts
rather than the whole day at once.
The individual may need the schedule posted on the wall or may be able to carry the schedule in a binder with
her wherever she goes. The schedule may be arranged left to right or top to bottom. The variety of materials
that can be used to create a schedule is endless. Individual schedules may look very different and be
implemented very differently depending upon the person using it.
A visual cue is necessary to communicate to the individual when it is time to check the schedule. For example,
this may be an arbitrary object such as a red block or a Koosh ball for the individual who needs objects.
Another example is a 3X5 index card with the person’s name written on it. This is always paired with the
verbal phrase, “check schedule.” A person who is able to follow a written schedule may need only the verbal
phrase. However, for anyone who is not at this level, a transition object is critical to the successful
implementation of the schedule.

The following is an example of the implementation of a schedule with an individual. Joe’s schedule is mounted
on the wall just inside the classroom door. Joe is given an index card with his name on it that indicates he
needs to check his schedule. When he arrives at the schedule, there is a place for him to put the card. The
schedule is arranged left to right, and the picture symbols are attached with Velcro. He removes the picture
symbol farthest to the left that says gym because it is time for P.E. class. Joe takes the picture symbol with
him to class and when he arrives at the gym, there is a place for him to match the symbol. When class is
over, the teacher gives him another card with his name on it which takes him back to the schedule and the
process begins again.
Mini-schedules are used to supplement the daily schedule. For example, the daily schedule indicates that it is
time for reading class. The mini-schedule tells the student that he is going to 1) read a book, 2) listen to the
teacher, and 3) do a worksheet. When the student has completed the activities on the mini-schedule, he is
prompted to transition back to the daily schedule.
Joe’s Schedule (an example of a visual schedule)

Enhancing Language and Communication in
Individuals with Autism
General Strategies
Minimize asking the individual
direct questions.
Watch what the individual is doing
and make appropriate comments.
For example, when a child puts a
doll in the cradle, say “Baby is
going to sleep.”
Wait for the individual to respond
with clear visible anticipation of
their response. Look expectantly
by establishing eye contact, with
lips slightly apart, eyebrows raised
and lean your head and body
slightly toward the individual.
Create communication
temptations. Set up situations
where the individual will have to
talk to get her needs met.
Use exaggerated facial features
and gestures.
Provide a model of appropriate
language.
Speak in concise, concrete
language that is appropriate to the
individual’s level of language.
Try using exaggerated intonation,
volume (soft or loud) and rate of
speech. This will capture the
attention of the individual.
Encourage eye contact, but do not
force the individual to give eye
contact.
Respond to any of the individual’s
verbal and nonverbal attempts to
communicate. Responding
consistently reinforces the
individual’s effort to communicate
and helps to establish motivation.
Individuals Who
Are Nonverbal
Teach joint attention by
engaging individuals with
toys and motivating
activities.
Teach imitation skills.
Develop turn-taking skills.
Teach gestures associated
with greetings.
Teach pointing skills.
Teach functional
communication skills to
replace unconventional
communication such as
screaming, aggressive
behavior or throwing
objects.
Create opportunities for
the individual to initiate
communication (also
called communication
temptations).
Encourage but do not
force eye contact.
Talk to the individual on
his physical level.
Teach the child to initiate
by first engaging her in a
social interactive game
such as peek-a-boo, hide-
and-seek, or a tickle game
and then waiting for her to
initiate a continuation of
the game or to begin the
game.
Individuals Who
Are Verbal
Teach vocabulary through
joint activities and
routines.
In familiar contexts,
substitute higher level
vocabulary for a familiar
word. Use the word
repeatedly while
demonstrating the
meaning.
Use photo albums to
discuss past events and
calendars to discuss future
events.
Introduce new topics of
conversation.
Expand the individual’s
pragmatic language skills
(pp. 36-38).
Teach conversational rules
such as initiating,
terminating a
conversation, changing
topics, signaling, and
repairing communication
breakdown.
Assist the individual to
understand and anticipate
the perspectives of others.
Expand the individual’s
language functions, i.e.,
understanding humor,
sarcasm, and idioms, the
use of figurative language,
problem solving with
language, narration, and
language to compare and
contrast.
Individuals Who
Are Using Minimal
Language
Keep language learning
fun!
Use gestures and facial
expressions.
Use gestures to teach
pronouns.
Fade prompts quickly to
reduce the occurrence of
prompt dependency.
Expand language by
adding another word to
the individual’s one word
utterance, and then
prompt them to repeat the
entire expanded
utterance.
Comment about what the
individual is doing.
Speak to the individual in
short, concise sentences
and phrases. This will
maximize comprehension
and provide a model for
him to imitate.
Use exaggerated
intonation, volume and
rate of speech; however,
be careful that the
individual does not echo
the language
inappropriately.
Use singing and music.

Strategies to Address Echolalia: Modeling
Functional Communication
REQUESTING If the child reaches for, points to or moves your hand
toward a ball, model “ball” or “want the ball” or “Sarah wants the ball” as
you give it to her. If he says, “You want a cookie?” you say “David wants
a cookie” as you give it to him. He may later spontaneously say, “David
wants a cookie,” which is still a delayed echo but provides a more appropriate
intermediate step between the echoed question as request and the more
natural form, “I want a cookie.” Avoid direct praise such as “good talking,”
which is likely to be echoed without comprehension.
CHOOSING For the child who cannot respond to a verbal choice such as
“Do you want crackers or an apple?” omit the question for a while. Show the
two items and say, “Crackers…apple…Matthew wants….” If he names one
and reaches for it, confirm his choice and give it to him, saying something like
“Matthew wants an apple.” Avoid saying “You want an apple” or “Okay,
here’s your apple,” as he may use your statement as a spontaneous request
next time he wants an apple. If he says nothing and just grabs one, name it
for him as you give it to him, saying “apple,” and pausing to see if he echoes
before you release the apple. If he doesn’t, just say it again and give it to
him. When he’s reliably choosing with a fill-in-the-blank format, you can
gradually build back up to the natural question form.
GREETING Avoid saying “Hi, Andrew,” to a child who repeats back “Hi,
Andrew.” Just say “Hi” or “Bye” without adding his name. If you need to get
his attention first, say “Andrew!” and then “Bye.” He may be more likely to
respond if you bridge the gap between you and him by bending down and
putting his hand on your shoulder to direct his attention. Encourage others to
use words and phrases that will be acceptable if echoed, such as “See you
later” rather than farewells like “Come again soon, Honey,” that are
inappropriate if echoed by the person who is leaving.
REJECTING/PROHIBITING If the child pushes away food or screams
at having her face washed, help her push the food away, or back off and say,
“No cake! Don’t want cake!” or “Stop!” or “No washing face!” Sometimes you
can accept the refusal, but in other cases, you will have to overrule the child.
If so, pause, say something empathetic like “Don’t like face washing,” and
then go on, “Becca’s face is dirty. Mommy has to wash it.” If someone takes
her toy, help her pull it back and model “Stop!” or “No!” or “Don’t take it!”
“Our child started to
really talk when he was
4½ to 5 years old. Of
course, one of the first
phrases he said was ‘Shut
up!’ We would then tell
him, ‘No, no, be quiet.’
He would then say, ‘Shut
up, no, no, be quiet.’ He
still does this.”
“One day I was very
angry because I had just
dented our brand new
van. My pre-adolescent
son said, ‘You need
GX27, it removes
unsightly rust and
scratches.’ He used the
same intonation as the
commercial and said it as
a way to make me feel
better.”
Echolalia is the repetition of previously heard words or phrases. There are two basic types of echolalia:
immediate and delayed. Immediate echolalia is the repetition of words and phrases that occurs immediately
or very soon after the original words. Delayed echolalia is the repetition of words or phrases that are echoed
hours, days, or weeks after they were originally heard. Both may serve a variety of functions for
communication for the individual. Echolalia occurs in approximately 85% of children with autism who
eventually develop speech. In many cases, the individual may learn to use echolalia in a functional way.

DIRECTING If he hands you objects to fix or open, puts your hand on an object, or just screams in
frustration, you can say “Please help” or “Need help” or “Open it,” as if directing yourself. Don’t say it with a
questioning intonation like “Need help?” or else the child will probably say it that way. Depending on the
child’s readiness and state of attention at the moment, you can wait for him to echo or just proceed to the
needed action. Be careful how you respond when the child does repeat your model. If you say “OK” several
different times, he may begin to say “Please help OK.” To avoid creating an inappropriate pattern, either do
the requested action without comment or vary your verbal response.
COMMENTING Modeling comments is useful not only for building vocabulary and concepts, but also as an
early social and pre-conversational activity. It provides many opportunities to use echoing as a teaching tool
and supplies the child with appropriate language to practice as he does the same actions during solitary play.
When doing a puzzle, you could say, “Here’s the horse…going to put it in…uh-oh, doesn’t fit…there, it’s in!”
Time your words to match the child’s independent or assisted action. If you’re looking at a book together,
start with wordbooks because noun vocabulary is often a strength and understanding of stories is apt to be
weak. To encourage visual focusing, use the child’s finger to point to pictures as you model comments
depending on the child’s level of comprehension, like “Shoes…hat,” “Here’s the brown puppy,” “The girl is
painting a picture,” “ Flowers on the table,” “The baby is crying, he’s sad.” If he does not spontaneously name
some, put his finger on a picture so he knows—and pause. The established pattern of point and name, and
your silence, will often elicit a spontaneous label from the child.
SOME IMPORTANT POINTS TO REMEMBER
• Model language structures that are only slightly longer and more complex than those you’ve heard the
child use meaningfully.
• Say things that match what’s happening from the child’s point of view.
• Avoid questions and verbal instructions.
• Use people’s names if pronouns are confusing.
• Use words and intonation that will be appropriate and accurate if echoed.
• Respond to the child’s speech with words and actions that confirm your understanding of the message,
not with praise, which may be echoed.
• Relax, enjoy yourself, join the child’s activity and follow his lead in play while gradually encouraging
more varied and appropriate use of toys.
• Remember that most children who echo are actively trying to communicate despite their confusion
about communicative functions, conversationalroles and the meanings of concepts that vary as
speakers and situations change. The procedures suggested here tap their strong memories, need for
predictable patterns and echoic tendencies to begin to establish a basis of meaningful, functional
communication.

Communication Temptations
1. Eat a desired food item in front of the child without offering any to him or her.
2. Activate a wind-up toy, let it deactivate, and hand it to the child.
3. Give the child four blocks to drop in a box, one at a time (or use some other action the child will repeat,
such as stacking the blocks or dropping the blocks on the floor); then immediately give the child a small
animal figure to drop into the box.
4. Open a jar of bubbles, blow bubbles, and then close the jar tightly and give the closed jar to the child.
5. Initiate a familiar social game with the child until the child expresses pleasure, then stop the game and wait.
6. Blow up a balloon and slowly deflate it; then hand the deflated balloon to the child or hold the deflated
balloon up to your mouth and wait.
7. Offer the child a food item or toy that he or she dislikes.
8. Place a desired food item in a clear container that the child cannot open; then put the container in front of
the child and wait.
9. Roll a ball to the child; after the child returns the ball three times, immediately roll a different toy to the
child.
10. Engage the child in putting together a puzzle. After the child has put in three pieces, offer the child a
piece that does not fit.
11. Engage the child in an activity with a substance that can be easily spilled (or dropped, broken, torn);
suddenly spill some of the substance on the table or floor in front of the child and wait.
12. Put an object that makes noise in an opaque container and shake; hold up the container and wait.
13. Give the child materials for an activity of interest that necessitates the use of an instrument for
completion (e.g. a piece of paper to draw on or cut; a bowl of pudding or soup); hold the instrument out
of the child’s reach and wait.
14. Engage the child in an activity of interest that necessitates the use of an instrument for completion (e.g.,
pen, crayon, scissors, stapler, wand for bubbles, spoon); have a third person come over and take
the instrument, go sit on the distant side of the room while holding the instrument within the child’s
sight, and wait.
15. Wave and say “bye” to an object and remove it from the play area. Repeat this for a second and third
situation, then do nothing when removing an object from a fourth situation.
16. Hide a stuffed animal under the table, knock, and then bring out the animal. Have the animal greet the
child the first time. Repeat this for a second and third time, then do nothing when bringing out the
animal for the fourth time.

Picture Exchange Communication System
The Picture Exchange Communication System (PECS) was developed in 1987 by Lori Frost MS, CCC/SLP and
Dr. Andrew Bondy. PECS is primarily implemented for individuals who are nonverbal or use speech with
limited effectiveness to assist them in acquiring functional communication skills. PECS has received
international recognition. It does not require complex or expensive materials and can easily be implemented
by educators and family members.
The system emphasizes the importance of an individual with a communication deficit learning to approach a
communicative partner. A variety of prompting, shaping, and fading techniques are incorporated to
gradually improve and modify an individual’s use of the system. PECS begins with teaching the person to
exchange a picture of a desired item or activity with another person, a communication partner, who
immediately honors the request. Verbal prompts are not used, thus building immediate initiation and
avoiding prompt dependency. Once this step is mastered, the indiv idual advances to the next phases of the
system, which teach discrimination of symbols and then puts them together in simple “sentences” such as “I
want ________.” The final of the six phases teaches the individual to respond to a question and comment in
response to a question.
The system can be successfully implemented with children as young as 2 years. Some parents worry that
the introduction of a communication system other than speech will interfere with the child’s development of
speech. However, research demonstrates that the opposite is true. The implementation of PECS enhances
the child’s language development. In summary, there are many advantages to PECS including 1) the
communication exchange is clearly understood, 2) the individual initiates the interaction, therefore
eliminating prompt dependency, and 3) the communication is meaningful and highly motivating.
For more information: www.pecs.com

A.P.P.R.E.C.I.A.T.E. the Child with Autism
The following, written by Cheryl S. Merritt, is reprinted with permission from the Northern Virginia Chapter of
the Autism Society of America.
A Behavior Management Program
A. Accept the child.
The first step in developing a behavior management program for a child with autism is to view the child as
wonderful and capable so he can live up to our expectations. The power of expectation is tremendous. If we
view a child’s behavior as bizarre simply because he has the label of autism we will not be able to see the
communicative intent of the behavior. We all have behaviors in private that we suppress when someone
walks into the room. We often forget that children with autism do not suppress behaviors to conform to social
expectations and therefore, we view them as bizarre.
P. Patience.
Children with autism often have a great deal done for them or to them. If we are to convey to the child our
belief in his capabilities, we must allow him the time to do things for himself. Our society tends to promote
the expectation of a fast response. Children with autism may have a 15-20 second delay (or longer) in
response time. That is a very long delay and requires lots of patience.
P. Perspectives.
It is important to view behavior from a variety of perspectives, i.e., medical, sensory, communicative, etc., and
perhaps try various interventions. Any change in behavior (positive or negative) should first be viewed from a
medical perspective. Some children display decreased hyperactivity and greater attentiveness during illness.
Sometimes a behavior is an attempt to decrease pain. Sometimes we get caught in the trap of viewing all
behavior from one perspective only. For example, my son was observed running his fingers along the brick
wall in his classroom. Like many children with autism, he has a history of sensory difficulties. This behavior
was initially viewed as his need for sensory input. Further investigation revealed the true meaning of the brick
wall. My son has a computer game which contains walls which will sometimes open to reveal hidden rooms.
Once he was told there were no hidden rooms in the classroom, the “problem” was alleviated.
R. Rules.
We all make sense of the world by developing rules to live by. A child with autism develops his own unique
rules and lacks the communicative ability to tell you what those rules are. For example, a child with autism
was sitting at the table having a snack. He suddenly jumped up from his chair and started screaming.
Because the behavior was so sudden and disconcerting, attention was focused on the child. A review of the
environment revealed that the “snack” included crackers in star shape. This child had developed a rule that
crackers are round or square and this star shape broke his rule. It is a common occurrence for a child with
autism to display unwanted behaviors in an attempt to convey that someone has broken a rule or that
something is different.
E. Everything has to be taught and everything has to be specific when working with a child with
autism.
In teaching my son to buy ice cream in a store, we broke it down into steps and daily repeated the routine.
One day we went into the store. David strode confidently to the counter and said, “David wants vanilla.”
There was no clerk in sight – he was in the back of the store on the telephone. We had failed to teach David

that the clerk needed to be present. What is obvious to most people is not to a child with autism. This
includes communication. For example, I was taking some things out of the refrigerator. My son David was
nearby and I asked him to “close the door.” David left the room and closed the back door. Even though I was
standing by an open refrigerator door, David did not understand. A child with autism does not attend to
subtle environmental clues.
C. Choices.
Making choices allows one to gain a sense of control over the environment. It is a step toward independence.
Allow children with autism the opportunity to make choices whenever possible. But be sure you are offering a
choice. We sometimes use language to be polite that may be misinterpreted by a child with autism. “Would
you like to go out to play now?” or “Are you ready for lunch?” implies a choice. Also remember that some
children will answer “yes” to anything you say but not really want what you offer. Sometimes problems are
created when choices are not allowed. One day I received a call about a “problem behavior” for a young
teenager with autism. It seems the teenager had taken to throwing his lunch in the trash can rather than
eating it. Further investigation revealed that the teacher was telling the teenager to eat his sandwich before
he ate his dessert. This battle resulted in the lunch ending in the trash can. A discussion with the mother
revealed that the teenager “normally” ate his dessert before he ate his sandwich but always ate well and she
wasn’t concerned. Once the teacher understood this, he agreed that the teenager should be allowed the
choice.
I. Inform.
Tell a child with autism what is going to happen and when. This is particularly important when there is going
to be a change in the routine or the environment. The way the information is conveyed may vary depending
on the child’s needs. Sometimes pictures or lists are used. Some children can use clocks and calendars.
A. Accommodations.
Although we all require accommodations for our needs, we often do not give the same respect to a child with
a disability. When most children start preschool they take a favorite toy and enjoy a comforting hug from an
adult. My son does not take his comfort in the same manner so he took a box and blanket to school.
Although he started out in the box with a blanket over his head, he quickly adjusted and in a few weeks the
accommodation was removed. Accommodations may be a trampoline in the classroom and home, earphones
while shopping, or standing at the end of a line for a child sensitive to touch.
T. Teach Social Rules and Expectations.
A child with autism has more than a language disability. He has a social disability. The child has to be taught
not only how to socially interact but when. For example, we can teach a child to hug and kiss but we also
need to teach when and with whom this is appropriate. Most children learn many things through observation
but children with autism have to be taught specific social expectations. This may include using low voices in
certain environments, i.e., library, movie theater, or refraining from socially inappropriate behaviors in public.
E. Exercise.
A daily, vigorous exercise program is essential to any behavior program. There is increasing evidence that
vigorous exercise is helpful to children with autism by reducing inappropriate behaviors and increasing their
ability to concentrate.

Functional Assessment of Challenging
Behaviors
Challenging or problem behaviors result when an individual is not able to communicate his needs or desires
effectively. Therefore, the challenging behavior serves a purpose for communicating, or a communicative
function. Generally, there are two categories of functions that a challenging behavior serves: 1) to obtain
something, or 2) to avoid something. Challenging behaviors often interfere with an individual’s learning, social
acceptance and opportunities for inclusion in their community. Extreme challenging behaviors can be
dangerous or even life threatening to an individual and others.
Functional assessment is a process for examining the relationship
between a person’s challenging behavior and the environment. One goal
of a functional assessment is to identify antecedents or environmental
situations that will predict the occurrence and nonoccurrence of the challenging
behavior. Another goal is to gain information that will improve the
effectiveness and efficiency of intervention strategies. Finally, a functional
assessment should identify the functions the behaviors appear to serve for the
person allowing us to teach an alternative replacement behavior.
A functional assessment can be conducted in a variety of ways. There are
three general methods for collecting functional assessment information. The
first is interviews and rating scales that provide information by talking with the
individual and/or to the people who know the individual best. The second
method is direct observation of the individual in her normal daily environments.
Direct observation confirms information gathered in the interview. One
strategy for collecting information is the A-B-C format. The observer records
the antecedent to the behavior (what happened immediately before the
behavior), description of the behavior, and the consequence of the behavior
(what happened immediately after). By analyzing the information obtained
through these two methods, a hypothesis can be developed. The hypothesis is
a best guess as to the function that the behavior serves for the individual
based on actual data. Interventions and behavior plans should be written
based on the function of the behavior. These interventions typically involve
teaching an alternative replacement behavior that serves the same purpose as
the challenging behavior and usually is communication based.
The third method of functional assessment is functional analysis. Functional analysis is the actual
manipulation of variables that reduce, eliminate or provoke the behavior to verify that the hypothesis is
correct. A functional analysis is the most precise and controlled method for conducting a functional
assessment. However, functional analyses are typically conducted in a controlled clinic environment and are
difficult to conduct in a classroom, although this has been done.
Functional assessment has been established as a professional standard. In 1988, the Association for Behavior
Analysis published “A Right to Effective Treatment,” (Van Houten, et al.) which includes the right of all
individuals who receive behavioral intervention to a professionally competent functional assessment. In 1989,
the National Institutes of Health strongly endorsed the use of functional assessment procedures. Several
states have since instituted laws or state regulations that require a functional assessment prior to the
implementation of significant behavioral interventions. The 1997 revisions to the Individuals with Disabilities
Education Act (IDEA) stipulates that a functional assessment be completed and a behavioral intervention plan
be implemented for a student prior to a suspension or making an alternative placement.
“Our son has a very
identifiable chain of
behaviors that occur
when he is getting
frustrated or angry. I
have written these
behaviors down for all the
people who work with
him so that they can help
interfere with the chain to
avoid his self-injurious
behaviors. The problem
is, sometimes they occur
so fast that the whole
chain is done in a matter
of seconds.”

Positive Behavioral Support
Positive Behavioral Support (PBS) is an approach that has evolved from the traditional behavioral management
approaches. Rather than attempting to eliminate the challenging behavior, the PBS process results in a multi-
component behavioral plan that seeks first to understand and identify the communicative function of the
behavior. The plan incorporates methods for changing the behavior that are respectful of the person’s dignity,
enhance his strengths and capabilities, and expand his opportunities and quality of life. The process is team-
driven and person-centered. Therefore, any outcomes are meaningful from the perspective of the individual’s
likes and dislikes, strengths and weaknesses. A person’s team should consist of family members,
professionals, and anyone else who can assist in providing support such as community members, employers,
or even peers.
There are five phases necessary to develop a comprehensive positive
behavioral support plan:
• Do functional assessment of the problem behavior. The goal of a
functional assessment is to understand the person and the nature of the
challenging behavior in the context of his environment. (See also
“Functional Assessment of Challenging Behavior,” previous page.)
• Develop hypothesis statements based upon the information. In
other words, the hypothesis is the team’s best guess as to why the person
engages in the challenging behavior.
• Develop intervention strategies. Ultimately the goal of the intervention
strategies is to make the challenging behavior ineffective and inefficient
and to teach the person new skills that serve the same communicative
function as the behavior.
• Implement the plan and keep data.
• Evaluate the effectiveness of the plan and make modifications as
needed.
“My son has autism and he
is very high-functioning.
He plays a musical
instrument. If he needs
help while he is playing, he
will not call out for me, but
instead, he will play his
instrument in a pleading or
insistent melody. I have
learned that this means
that he needs me and I
should come into his
room.”
********
“Our child is non-verbal.
One thing I don’t
understand is why doctors
talk louder to him. They
know he is not deaf.”

General Recommendations for Promoting
and Enhancing Socialization
• Structure and facilitate opportunities for social interaction in natural environments with typically
developing peers that are consistent and predictable.
• Guide the child’s play and provide support as needed by modeling and directing play or giving verbal
prompts.
• Teach the social rules of play: how to start, maintain and end; how to be flexible and cooperative;
how to share; and how to maintain solitude without offending others.
• Use other children as cues to indicate what to do.
• Encourage participation in social interactive games such as hide and
seek, peek-a-boo, and pat-a-cake.
• Play areas should be structured to promote interaction. Avoid large
open spaces. The space should be clearly defined by boundaries. Toys
and materials should be visible and easily accessible.
• Create a social support group that consists of the individual’s peers.
• Provide detailed scripts for the individual to follow.
• Teach the individual strategies to help him express and understand
emotion.
• Teach the individual to “read” social situations by using techniques such
as Social Stories, Social Review, and Social Assistance Activities.
• Facilitate a social skills group to teach important appropriate social behaviors through role playing and
modeling.
• Seek out clubs or groups for the individual to participate in that center on her interests.
• Teach individual how to make and maintain friendships.
“We have a daughter
whose main job is to
make sure I don’t dress
our son with autism like
‘a geek’ (her words). Our
son doesn't care how he
looks, and I don’t pay
attention to the styles.
Her advice is invaluable
to his social position at
school!”

Social Stories
Social stories are written by parents or professionals to describe social situations that are difficult and/or
confusing for an individual with autism. They assist an individual with identifying relevant social cues,
understanding, and responding appropriately to specific social situations. When writing a social story, the
person’s interests, learning styles, and abilities should be considered.
Carol Gray has developed a formula for writing effective social stories. She has identified three types of
sentences contained in a basic social story. Descriptive sentences define where a situation occurs, who is
involved, what they are doing and why. Perspective sentences describe the reactions and feelings of others in
a given situation. Directive sentences are positively stated, individualized statements describing desired
responses. They often begin with “I can try…,” “I will try…,” or “I will work on….” Directive sentences that are
inflexible or that require absolute compliance should be avoided. Her formula for an effective social story is
two to five descriptive and/or perspective sentences for every directive sentence.
Social stories are usually written in the first person and the present tense as though the person is describing
the situation as it occurs. It can be written in the future tense to describe an upcoming event or situation.
Words like “always” and “never” are avoided since they may lead to inaccurate information. The desired
responses must be stated very carefully and specifically. Ambiguous or abstract terms must be functionally
defined. For example, instead of “I will talk quietly,” write “I will talk quietly. I will talk so that only the
person sitting next to me can hear what I say.” Additionally, it is important to write in reality and mention
variations that may occur in the routine. Illustrations accompanying the story can also aid the person’s
comprehension. However, illustrations may define a situation too narrowly or be distracting.
There are four steps to writing a social story:
1) Target a situation — identify and describe the situation
2) Gather information
3) Share observations
4) Support new responses and/or revise the story based on the person’s responses
While social stories are a generic strategy, following Carol Gray’s guidelines can increase the quality and
effectiveness of the story.
My name is Joe. Mrs. Smith is one of my teachers. Sometimes
Mrs. Smith asks me a question. Sometimes she asks a question
to the whole class. I will know she wants me to answer her
question out loud when she first says my name and then asks
the question. If she does not say my name, I need to raise my
hand and wait for Mrs. Smith to ask for my answer. I will try to
raise my hand to give answers in class.
Example of a Social Story

Comic Strip Conversations
Developed by Carol Gray, a Comic Strip Conversation is a conversation between two or more people that
incorporates the use of simple drawings. They provide a visual representation of a conversation in order to
enhance the person’s understanding and comprehension. While the conversation takes place or a situation is
recounted, illustration is added. The illustration can include symbols, drawings and written words. The joint
attention of the individuals involved with the conversation is focused on the drawing surface. While this
strategy is helpful in sharing information with the person with autism, it is also helpful in obtaining their
perspective, and assisting them in communicating their own feelings and ideas.
A specific structure is followed to organize a social exchange, and build in predictability. Comic Strip
Conversations are not intended to be used for every conversation. They are most helpful when there is a
need to convey important information, when there is a misunderstanding, or to solve a problem. A Comic
Strip Conversation may also be used to teach a social skill. The illustrations usually consist of stick figures and
bubbles where the figures words and thoughts are written. When a person gains experience with using Comic
Strip Conversations, colors can be associated to express feelings such as green for happy, blue for sad, or
black for anger.
The conversation usually begins with small talk, just as any conversation usually does. The person with
autism takes the lead in a Comic Strip Conversation, and the parent, professional, or peer serves as a guide to
the conversation. The interaction is illustrated as it progresses. The conversation then moves from small talk
to talking about the situation. Information such as where and when the situation takes place, and who is
there, what is done and said is covered. Next, Comic Strip Conversations focus on what people in the situation
may be thinking. Often the person with autism may have difficulty interpreting what someone else may be
thinking, or they may interpret something that was said literally. This presents an opportunity to assist them
in understanding the situation, or another person’s perspective. Finally, the conversation is summarized, and,
if necessary, concluded with the identification of new solutions.
Example of a Comic Strip Conversation
I love talking about
suspension bridges.
I am bored.

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